The Cleveland Group, Inc.

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MEDICAL PLAN
2017 Employee Benefits
7
Type of Plan
In-Network Out-of-Network
Overview
Single $2,600 $5,000
Family $5,000 $10,000
Annual Out-of-Pocket Maximum
Single $5,000 $10,000
Family $10,000 $20,000
Maximum Annual Benefit
PCP/Specialist Care (Outpatient) 70% covered after deductible 50% covered after deductible
Hospital Inpatient Care 70% covered after deductible 50% covered after deductible
Hospital Outpatient Surgery 70% covered after deductible 50% covered after deductible
Emergency Services (copay waived if admitted) 70% covered after deductible 50% covered after deductible
Preventive Health Care Benefit
100% deductible waived,
based on age appropriate recommendations*
100% deductible waived,
based on age appropriate recommendations*
Chiropractic Care
70% covered after deductible,
up to 30 visits annually
50% covered after deductible,
up to 30 visits annually
Inpatient 70% covered after deductible 50% covered after deductible
Outpatient 70% covered after deductible 50% covered after deductible
Skilled Nursing Facility, Hospice Care, Home
Health Care, DME/Prosthetics, Speech and
Occupational Therapy
70% covered after deductible,
up to plan limits
50% covered after deductible,
up to plan limits
Retail Pharmacy (30 days)
Generic/Brand
Mail Order Delivery (90 days)
Generic/Brand
Employee
Employee & Spouse
Employee & Child/ren
Employee & Family
Eligibility Date
Contact Information
Provider Finder
* For more information on age appropriate recommendations, please see your Summary Plan Description.
$24.98
70% covered after deductible
Not covered 70% covered after deductible
Not covered
$55.01
Bi-Weekly Contribution
Meritain Health - Policy Number 12217
HDHP
You may use both In-Network and Out-of-Network providers.
Receive the highest level of benefits with use of the In-Network providers.
Annual Deductible
Unlimited
Mental Health
Long Term Care Services
Prescription Drugs
$79.99
$44.97
Select Aetna Choice POS II (Open Access) Network
Date of Hire - All full-time employees who work at least 30 hours per week.
Meritain Health 1.800.925.2272
* For more i f ti ti s, lease s e your Su ary Plan Description.